Water Supply Interruptions Are Associated with More Frequent Stressful Behaviors and Emotions but Mitigated by Predictability: A Multisite Study.

Water supply interruptions contribute to household water insecurity. Unpredictable interruptions may particularly exacerbate water insecurity, as uncertainty limits households' ability to optimize water collection and storage or to modify other coping behaviors. This study used regression models of survey data from 2873 households across 10 sites in 9 middle-income countries to assess whether water supply interruptions and the predictability of interruptions were related to composite indicators of stressful behaviors and emotional distress. More frequent water service interruptions were associated with more frequent emotional distress (ß = 0.49, SE = 0.05, P < 0.001) and stressful behaviors (ß = 0.39, SE = 0.06, P < 0.001). Among households that experienced interruptions, predictability mitigated these respective relationships by approximately 25 and 50%. Where the provision of continuous water supplies is challenged by climate change, population growth, and poor management, water service providers may be able to mitigate some psychosocial consequences of intermittency through scheduled intermittency and communication about water supply interruptions. Service providers unable to supply continuous water should optimize intermittent water delivery to reduce negative impacts on users, and global monitoring regimes should account for intermittency and predictability in post-2030 water service metrics to better reflect household water insecurity experiences.

The Impact of Rapid Handpump Repairs on Diarrhea Morbidity in Children: Cross-Sectional Study in Kwale County, Kenya.

BACKGROUND: Handpumps are used by millions of people as their main source of water. Although handpumps represent only a basic form of water provision, there have been continuous efforts to improve the performance of these systems as they are likely to remain in use for many years to come. The introduction of a professional maintenance service in southern Kenya has shown an order of magnitude improvement in operational performance over community-based management, with 90% of handpump faults repaired within 3 days of being reported. One driver behind these efforts is the assumption that a more reliable water supply will lead to a reduction in water-related disease. However, it is not clear if operational improvements lead to health gains. Despite limited empirical evidence, some modeling studies suggest that even short periods of drinking contaminated water can lead to disproportionate negative health impacts. OBJECTIVE: The aim of this study was to assess whether the improvements in operational performance from the rapid professional maintenance of rural handpumps lead to improved household health outcomes. METHODS: From a sample of households using handpumps as their primary water source in Kwale County, Kenya, we measured the 2-week prevalence of World Health Organization-defined diarrhea in children, reported by the adult respondent for each household. We compared the rates before and after a period during which the households' handpumps were being professionally maintained. We then conducted a cross-sectional analysis, fitting logistic regression models with reported diarrhea as the dependent variable and speed of repair as the independent exposure of interest, adjusting for household socioeconomic characteristics; dwelling construction; and Water, Sanitation, and Hygiene (WASH)-related factors. We fitted an additional model to examine select interactions between covariates. RESULTS: Reported diarrhea in children was lower in households whose pumps had been repaired within 24 hours (adjusted odds ratio 0.35, 95% CI 0.24-0.51). This effect was robust to the inclusion of multiple categories of covariates. No reduction was seen in households whose pump repairs took more than 24 hours. Analysis of interaction terms showed that certain interventions associated with improved WASH outcomes were only associated with reductions in diarrhea in conjunction with socioeconomic improvements. CONCLUSIONS: Only pump repairs consistently made within 24 hours of failure led to a reduction in diarrhea in the children of families using handpumps. While the efficacy of reduction in diarrhea is substantial, the operational challenges of guaranteeing same-day repairs limits the effectiveness of even best-in-class pump maintenance. Maintenance regimes that cannot bring handpump downtimes close to zero will struggle to generate health benefits. Other factors that reduce diarrhea prevalence have limited effect in isolation, suggesting that WASH interventions will be more effective when undertaken as part of more holistic poverty-reduction efforts.

Associations Between Neighborhood-Level Income and Triple-Negative Breast Cancer in a Majority-Minority Population.

BACKGROUND: Previous studies on disparities in triple-negative breast cancer (TNBC) focus on race/ethnicity, with few exploring the impact of contextual factors such as neighborhood-level income. This study evaluates the effect of neighborhood-level income on disparities in TNBC among a racially and ethnically diverse cohort, after accounting for granular individual-level risk factors of TNBC. PATIENTS AND METHODS: Patients with stage I-IV breast cancer from 2005 to 2017 were identified from our local tumor registry. The primary outcome was diagnosis of TNBC. Using 5-years estimates from the American Community Survey, we obtained median household income for each census tract which was categorized into quartiles. Mixed effects logistic regression was conducted and stratified by race and ethnicity, controlling for individual-level sociodemographic, comorbidities, and tumor characteristics. RESULTS: Among 5377 breast cancer registry patients, 16.5% were diagnosed with TNBC. The majority were Hispanic (50.1%) followed by non-Hispanic Black (NHB) (28.0%). After controlling for individual-level covariables including race and ethnicity, comorbidities, and tumor characteristics, women from low-income neighborhoods had increased odds of TNBC compared with other breast cancer subtypes, compared with those in high-income neighborhoods [odds ratio (OR) 1.33; 95% confidence interval (CI) 1.04, 1.70, p < 0.001]. In stratified analyses, NHB patients from low-income neighborhoods had two times the odds of TNBC diagnosis compared with those from high-income neighborhoods (OR 2.11; 95% CI 1.02, 4.37). CONCLUSION: We found that living in a low-income neighborhood is associated with an increased odds of TNBC independent of granular individual-level TNBC risk factors, particularly NHB race. More striking, NHB living in low-income neighborhoods had increased odds of TNBC compared with NHB living in high-income neighborhoods. Our results suggest potential unaccounted gene-environment and/or social (api)genomic interactions between neighborhood-level income and TNBC subtype development.

A Multiscale Spatiotemporal Epidemiological Analysis of Neighborhood Correlates of Triple-Negative Breast Cancer.

BACKGROUND: Women living in disadvantaged neighborhoods present with increased prevalence rates of triple-negative breast cancer (TNBC). This study takes a spatiotemporal epidemiological approach to understand the impact of socioenvironmental contextual factors on TNBC prevalence rates. METHODS: We analyzed 935 TNBC cases from a major cancer center registry, between 2005 and 2017, to explore spatial and space-time clusters of TNBC prevalence rates at the census tract and neighborhood scales. Spatial regression analysis was performed to examine relationships between nine socioenvironmental factors and TNBC prevalence rates at both ecological scales. RESULTS: We observed spatial clustering of high TNBC prevalence rates along a north-south corridor of Miami-Dade County along Interstate 95, a region containing several majority non-Hispanic Black neighborhoods. Among the ecologic measures, the percent of a region designated as a brownfield was associated with TNBC prevalence rates at the tract-level (ß = 4.27; SE = 1.08; P < 0.001) and neighborhood-level (ß = 8.61; SE = 2.20; P < 0.001). CONCLUSIONS: Our spatiotemporal analysis identified robust patterns of hot spots of TNBC prevalence rates in a corridor of several disadvantaged neighborhoods in the northern half of the county. These patterns of TNBC align with the literature regarding at-risk groups and neighborhood-level effects on TNBC; however, remain to be validated in a population-based sample. IMPACT: Spatial epidemiological approaches can help public health officials and cancer care providers improve place-specific screening, patient care, and understanding of socioenvironmental factors that may shape breast cancer subtype through gene-environment and epigenetic interactions.

Frontiers of household water insecurity metrics: severity, adaptation and resilience.

The measurement of household-level and individual-level water insecurity has accelerated over the past 5 years through innovation and dissemination of new survey-based experiential psychometric scales modelled after food insecurity scales. These measures offer needed insight into the relative frequency of various dimensions of water problems experienced by households or individuals. But they currently tell us nothing about the severity of these experiences, mitigating behaviours (ie, adaptation) or the effectiveness of water-related behaviours (ie, resilience). Given the magnitude of the global challenge to provide water security for all, we propose a low-cost, theoretically grounded modification to common water insecurity metrics in order to capture information about severity, adaptation and resilience. We also discuss ongoing challenges in cost-effective measurement related to multidimensionality, water affordability and perception of water quality for maximising the impact and sustainability of water supply interventions. The next generation of water insecurity metrics promises better monitoring and evaluation tools-particularly in the context of rapid global environmental change-once scale reliability across diverse contexts is better characterised.

Pediatric Pedestrian Injuries: Striking Too Close to Home.

BACKGROUND: Pediatric pedestrian injuries (PPI) are a major public health concern. This study utilized geospatial analysis to characterize the risk and injury severity of PPI. METHODS: A retrospective chart review of PPI patients (age < 18) from a level 1 trauma center was performed (2013-2020). A geographic information system geocoded injury location to home and other public landmarks. Incidents were aggregated to zip codes and the Local Indicators of Spatial Association statistic tested for spatial clustering of injury rates per 10,000 children. Predictors for increased injury severity were assessed by logistic regression. RESULTS: PPI encompassed 6% (n = 188) of pediatric traumas. Most patients were black (54%), male (58%), >13 years (56%), and with Medicaid insurance (68%). Nine zip codes comprised a statistically significant cluster of PPI. Nearly half (40%) occurred within a quarter mile of home; 7% occurred at home. Most (65%) PPI occurred within 1 mile of a school, and 45% occurred within a quarter mile of a park. Nearly all (99%) PPI occurred within a quarter mile of a major intersection and/or roadway. Using admission to ICU as a marker for injury severity, farther distance from home (OR 1.060, 95% CI 1.001-1.121, p = 0.045) and age <13 years (3.662, 95% CI 1.854-7.231, p < 0.001) were independent predictors of injury severity. CONCLUSIONS: There are significant sociodemographic disparities in PPI. Most injuries occur near patients' homes and other public landmarks. Multidisciplinary injury prevention collaboration can help inform policymakers, direct local safety programs, and provide a model for PPI prevention at the national level. LEVEL OF EVIDENCE: Level IV.

Neighborhood Disadvantage and Breast Cancer-Specific Survival.

Importance: Neighborhood-level disadvantage is an important factor in the creation and persistence of underresourced neighborhoods with an undue burden of disparate breast cancer-specific survival outcomes. Although studies have evaluated neighborhood-level disadvantage and breast cancer-specific survival after accounting for individual-level socioeconomic status (SES) in large national cancer databases, these studies are limited by age, socioeconomic, and racial and ethnic diversity. Objective: To investigate neighborhood SES (using a validated comprehensive composite measure) and breast cancer-specific survival in a majority-minority population. Design, Setting, and Participants: This retrospective multi-institutional cohort study included patients with stage I to IV breast cancer treated at a National Cancer Institute-designated cancer center and sister safety-net hospital from January 10, 2007, to September 9, 2016. Mean (SD) follow-up time was 60.3 (41.4) months. Data analysis was performed from March 2022 to March 2023. Exposures: Neighborhood SES was measured using the Area Deprivation Index (tertiles), a validated comprehensive composite measure of neighborhood SES. Main Outcomes and Measures: The primary outcome was breast cancer-specific survival. Random effects frailty models for breast cancer-specific survival were performed controlling for individual-level sociodemographic, comorbidity, breast cancer risk factor, access to care, tumor, and National Comprehensive Cancer Network guideline-concordant treatment characteristics. The Area Deprivation Index was calculated for each patient at the census block group level and categorized into tertiles (T1-T3). Results: A total of 5027 women with breast cancer were included: 55.8% were Hispanic, 17.5% were non-Hispanic Black, and 27.0% were non-Hispanic White. Mean (SD) age was 55.5 (11.7) years. Women living in the most disadvantaged neighborhoods (T3) had shorter breast cancer-specific survival compared with those living in the most advantaged neighborhoods (T1) after controlling for individual-level sociodemographic, comorbidity, breast cancer risk factor, access to care, tumor, and National Comprehensive Cancer Network guideline-concordant treatment characteristics (T3 vs T1: hazard ratio, 1.29; 95% CI, 1.01-1.65; P < .04). Conclusions and Relevance: In this cohort study, a shorter breast cancer-specific survival in women from disadvantaged neighborhoods compared with advantaged neighborhoods was identified, even after controlling for individual-level sociodemographic, comorbidity, breast cancer risk factor, access to care, tumor, and National Comprehensive Cancer Network guideline-concordant treatment characteristics. The findings suggest potential unaccounted mechanisms, including unmeasured social determinants of health and access to care measures. This study also lays the foundation for future research to evaluate whether social adversity from living in a disadvantaged neighborhood is associated with more aggressive tumor biologic factors, and ultimately shorter breast cancer-specific survival, through social genomic and/or epigenomic alterations.

Sociodemographic Correlates of Affordable Community Behavioral Health Treatment Facility Availability in Florida: A Cross-Sectional Study.

Behavioral health disorders such as mental disorders (MD) and substance use disorders (SUD) are epidemics in the US; however, the availability of treatment and prevention services remains low. This study assessed neighborhood-level sociodemographic attributes to characterize the availability of behavioral health treatment facilities in Florida. The American Community Survey and SAMHSA's Behavioral Health Treatment Locator were used to identify behavioral health treatment facilities in Florida and calculate their density by census tract. Spatial lag regression models were used to assess census tract-level correlates of facility density for 390 MD treatment facilities, 518 SUD facilities, and subsets of affordable MD and SUD facilities. Behavioral health treatment facility density was negatively associated with rurality and positively associated with the proportion of non-Latino Black, Latino, insured, and college-educated populations. Stark rural-urban disparities in behavioral health treatment availability present opportunities to prioritize telehealth and mobile interventions and improve treatment utilization.

The Relationship Between Social Media Use and Beliefs in Conspiracy Theories and Misinformation.

Numerous studies find associations between social media use and beliefs in conspiracy theories and misinformation. While such findings are often interpreted as evidence that social media causally promotes conspiracy beliefs, we theorize that this relationship is conditional on other individual-level predispositions. Across two studies, we examine the relationship between beliefs in conspiracy theories and media use, finding that individuals who get their news from social media and use social media frequently express more beliefs in some types of conspiracy theories and misinformation. However, we also find that these relationships are conditional on conspiracy thinking--the predisposition to interpret salient events as products of conspiracies--such that social media use becomes more strongly associated with conspiracy beliefs as conspiracy thinking intensifies. This pattern, which we observe across many beliefs from two studies, clarifies the relationship between social media use and beliefs in dubious ideas. Supplementary Information: The online version contains supplementary material available at 10.1007/s11109-021-09734-6.

Geographic Disparities in Availability of Spanish-Language PrEP Services Among Latino Sexual Minority Men in South Florida.

Latino sexual minority men (LSMM) experience barriers in accessing HIV pre-exposure prophylaxis (PrEP), such as lack of proximate culturally-appropriate PrEP navigation services. We examined associations between LSMM's immigration status and Spanish-language PrEP service availability. LSMM clinically indicated for PrEP were recruited from October 2018 to August 2019 in South Florida and completed an interviewer-administered questionnaire. PrEP service navigators in South Florida were identified using the CDC PrEP Directory. We constructed network service areas of 1-, 2-, and 5-miles from Spanish-speaking PrEP navigators. We used multilevel logistic regression to examine associations of individual (i.e., age, income, immigration status, network density) and zip code-level (i.e., population density, poverty, HIV risk) measures with availability of Spanish-language PrEP navigation services. A total of 131 participants clustered into 60 zip codes in South Florida. Latin American-born LSMM reported higher immigration and discrimination stress, and were 91% less likely to have PrEP navigation service availability, relative to LSMM born in the US. Zip code-level HIV incidence was associated with higher service availability within a 1-mile network of Spanish-speaking PrEP navigators. Spanish-language PrEP navigation services were available in high-HIV incidence zip codes; however, Latin American-born LSMM experienced reduced availability. Immigration and discrimination stress may explain lack of availability.

Variations in household water affordability and water insecurity: An intersectional perspective from 18 low- and middle-income countries.

Compounding systems of marginalization differentiate and shape water-related risks. Yet, quantitative water security scholarship rarely assesses such risks through intersectionality, a paradigm that conceptualizes and examines racial, gendered, class, and other oppressions as interdependent. Using an intersectionality approach, we analyze the relationships between household head gender and self-reported socio-economic status, and water affordability (proportion of monthly income spent on water) and water insecurity (a composite measure of 11 self-reported experiences) for over 4000 households across 18 low- and middle-income countries in Central and South America, Africa, and Asia. Interaction terms and composite categorical variables were included in regression models, adjusting for putative confounders. Among households with a high socio-economic status, the proportion of monthly income spent on water differed by household head gender. In contrast, greater household water insecurity was associated with lower socio-economic status and did not meaningfully vary by the gender of the household head. We contextualize and interpret these experiences through larger systems of power and privilege. Overall, our results provide evidence of broad intersectional patterns from diverse sites, while indicating that their nature and magnitude depend on local contexts. Through a critical reflection on the study's value and limitations, including the operationalization of social contexts across different sites, we propose methodological approaches to advance multi-sited and quantitative intersectional research on water affordability and water insecurity. These approaches include developing scale-appropriate models, analyzing complementarities and differences between site-specific and multi-sited data, collecting data on gendered power relations, and measuring the impacts of household water insecurity.

MAD Water: Integrating Modular, Adaptive, and Decentralized Approaches for Water Security in the Climate Change Era.

Centralized water infrastructure has, over the last century, brought safe and reliable drinking water to much of the world. But climate change, combined with aging and underfunding, is increasingly testing the limits of-and reversing gains made by-these large-scale water systems. To address these growing strains and gaps, we must assess and advance alternatives to centralized water provision and sanitation. The water literature is rife with examples of systems that are neither centralized nor networked, but still meet water needs of local communities in important ways, including: informal and hybrid water systems, decentralized water provision, community-based water management, small drinking water systems, point-of-use treatment, small-scale water vendors, and packaged water. Our work builds on these literatures by proposing a convergence approach that can integrate and explore the benefits and challenges of modular, adaptive, and decentralized ("MAD") water provision and sanitation, often foregrounding important advances in engineering technology. We further provide frameworks to evaluate justice, economic feasibility, governance, human health, and environmental sustainability as key parameters of MAD water system performance.

How Anti-Social Personality Traits and Anti-Establishment Views Promote Beliefs in Election Fraud, QAnon, and COVID-19 Conspiracy Theories and Misinformation.

Conspiracy theories and misinformation (CTM) became a salient feature of the Trump era. However, traditional explanations of political attitudes and behaviors inadequately account for beliefs in CTM or the deleterious behaviors they are associated with. Here, we integrate disparate literatures to explain beliefs in CTM regarding COVID-19, QAnon, and voter fraud. We aim to provide a more holistic accounting, and to determine which political, psychological, and social factors are most associated with such beliefs. Using a unique national survey, we find that anti-social personality traits, anti-establishment orientations, and support for Donald Trump are more strongly related to beliefs in CTM than traditional left-right orientations or other frequently posited factors, such as education, science literacy, and social media use. Our findings encourage researchers to move beyond the traditional correlates of political behavior when examining beliefs that express anti-social tendencies or a deep skepticism of social and political institutions.

On the relationship between conspiracy theory beliefs, misinformation, and vaccine hesitancy.

At the time of writing, nearly one hundred published studies demonstrate that beliefs in COVID-19 conspiracy theories and misinformation are negatively associated with COVID-19 preventive behaviors. These correlational findings are often interpreted as evidence that beliefs in conspiracy theories and misinformation are exogenous factors that shape human behavior, such as forgoing vaccination. This interpretation has motivated researchers to develop methods for "prebunking," "debunking," or otherwise limiting the spread of conspiracy theories and misinformation online. However, the robust literatures on conspiracy theory beliefs, health behaviors, and media effects lead us to question whether beliefs in conspiracy theories and misinformation should be treated as exogenous to vaccine hesitancy and refusal. Employing U.S. survey data (n = 2,065) from July 2021, we show that beliefs in COVID-19 conspiracy theories and misinformation are not only related to COVID-19 vaccine hesitancy and refusal, but also strongly associated with the same psychological, social, and political motivations theorized to drive COVID-19 vaccine hesitancy and refusal. These findings suggest that beliefs in conspiracy theories and misinformation might not always be an exogenous cause, but rather a manifestation of the same factors that lead to vaccine hesitancy and refusal. We conclude by encouraging researchers to carefully consider modeling choices and imploring practitioners to refocus on the worldviews, personality traits, and political orientations that underlie both health-related behaviors and beliefs in conspiracy theories and misinformation.

Sociopolitical and psychological correlates of COVID-19 vaccine hesitancy in the United States during summer 2021.

Vaccine hesitancy and refusal continue to hamper COVID-19 control efforts. Throughout the pandemic, scientists and journalists have attributed lagging COVID-19 vaccination rates to a shifting set of factors including demography, experiences during the height of the pandemic, political views, and beliefs in conspiracy theories and misinformation, among others. However, these factors have rarely been tested comprehensively, in tandem, or alongside other potentially underlying psychological factors, thus limiting our understanding of COVID-19 vaccine hesitancy. This cross-sectional study assesses a diverse set of correlates of COVID-19 vaccine hesitancy identified in previous studies using US survey data (N = 2055) collected in July-August 2021. The survey contained modules designed to assess various sociopolitical domains and anti- and pro-social personality characteristics hypothesized to shape vaccine hesitancy. Using logistic and multinomial regression, we found that the strongest correlate of vaccine hesitancy was belief in misinformation about the COVID-19 vaccines, though we surmise that this common explanation may be endogenous to vaccine hesitancy. Political beliefs explained more variation in vaccine hesitancy-and in particular, vaccine refusal-after belief in COVID-19 vaccine misinformation was excluded from the analysis. Our findings help reconcile numerous disparate findings across the literature with implications for health education and future research.

Cause and effect: On the antecedents and consequences of conspiracy theory beliefs.

Since 2008, hundreds of studies have been published about conspiracy theories, many of which were in reaction to the COVID-19 pandemic. These studies are often motivated by concerns about the influence of exposure to conspiracy theories on beliefs, and the impact of conspiracy theory beliefs on behaviors. Numerous studies identify supportive correlations, concluding implicitly or explicitly that exposure causes belief and that beliefs subsequently cause behavior. We argue that while these causal relationships may exist, such conclusions currently lack robust evidence. We present an alternative model of the relationship between exposure, beliefs, and behaviors that accounts for other potentially causal factors and pathways. We encourage further work into the causal effects of exposure to, and beliefs in, conspiracy theories.

Analyzing pediatric bicycle injuries using geo-demographic data.

PURPOSE: Bicycle accidents are potentially preventable, and helmets can mitigate the severity of injuries. The purpose of the study it to investigate geo-demographic areas to establish prevention policies and targeted programs. METHODS: From October 2013 to March 2020 all bicycle injuries at a Level 1 trauma center were collected for ages ≤18 years. Demographics, injuries, and outcomes were analyzed. Incidents were aggregated to zip codes and the Local Indicators of Spatial Association (LISA) statistic was used to test for spatial clustering of injury rates per 10,000 children. RESULTS: Over the 8-year time period, 77 cases were identified with an average age of 13±4 years, 83% male and 48% non-Hispanic white. The majority of patients (98%) were not wearing a helmet. Loss of consciousness was reported in 44% and 21% sustained a traumatic brain injury. Twenty-eight percent required ICU care and 36% required operative interventions. There was only 1 mortality in the cohort (<1%).Injuries were more common in lower household income zip codes (Figure 1). Six zip codes encompassing several interstate exits and the connected heavy-traffic roadways comprise a statistically significant cluster of pediatric bicycle accidents (Figure 1). CONCLUSION: Low-income neighborhoods and those near major roadways held the highest risk for pediatric bicycle accidents. Use of helmets was extremely low in the patient population, with high rates of traumatic brain injury. With this information, targeted programs to address high-risk intersections, helmet access, and safety education can be implemented locally.